NEYC Child Enrollment Form

This field is for validation purposes and should be left unchanged.

Parent/Guardian Information

Primary Parent/Guardian Name(Required)
Address(Required)
Employer Name(Required)
Employer Address(Required)
Secondary Parent/Guardian Name
Address
Employer Name
Employer Address

Child Information

Child's Name(Required)
MM slash DD slash YYYY
Doctor Address(Required)
Dentist Address(Required)
Known Medical Conditions(Required)
Current Medications(Required)
Known Allergies(Required)
Special Dietary Needs(Required)
Please upload a complete copy of your child's immunization records. You may be able to access your child's records through: myirmobile.com or request a childcare copy of your child's immunization records from your child's PCP.
Drop files here or
Max. file size: 60 MB.

    Emergency Contacts and Approved Pickups

    You must list at least one emergency contact other than a parent/guardian.
    First Contact Name(Required)
    Second Contact Name
    Third Contact Name
    Fourth Contact Name
    Fifth Contact Name
    Terms and Conditions(Required)
    Name of Signer(Required)